Antibiotics in PHCs & MCs
OCBA - SYRIA Mission

Analyzing supplies of antibiotics from June to December 2023 against the data extracted from HMIS

5/15/23

Context

  1. Armed conflict with lots of displacements
  2. Working through partnership of DoH and local NGOs (MSF is NOT the direct implementer of services).
  3. Two projects: IDAL and NAP
  4. Supporting PHCs, MCs, BEmONCs and CEmONCs
  5. Regular monthly medical donations based on the facilities consumption
  6. AMR and Antibiotics over-prescribing are quiet spread in Syria

objectives

  1. Evaluate the antibiotic usage:
    is there Antibiotics over-prescribing in Facilities? where? how much? how often?
  2. Evaluate the rational prescribing behavior:
    are first line of ABs prescribed (Access group) or skipped to second line (Watch group) immediately?
  3. Double check the balance between antipyretic courses and antibiotics courses?

Data resources

  • Monthly donations extracted from Isystock (it is based on the facilities monthly consumption)
  • Export HMIS data for all health facilities (HF) for concerned period.
  • Age:
    • Under 5 years U5.
    • 5 years or more O5.
  • consultation categories:
    • Total consultations.

Parameters

  1. define the Antibiotics list in the mission and its category based on WHO AWaRE categorization (Access, Watch)
  2. define Age categories of those medications:
    • Under 5 years U5 (pediatrics: Suspension, Syrups, dispersible tablets and pediatrics injectables
    • 5 years or more O5: Tablets and injectables for adult

  1. Define the Duration of treatment based on MSF1 (the average duration of treatment of the main indication of the drug)
  2. WHO DDD: Daily defined dose is the assumed average maintenance dose (grams) per day for a drug used for its main indication in adults.
  3. Calculation of number of units of medication per course
    • Under 5 years U5:
      each bottle of suspension or syrup are 1 course.

  • 5 years or more O5:
    DDD * DoT / (dose of medication per unit in grams) Amoxicillin 500 mg =>
    DDD is 1.5 gram => duration of treatment is between 5 to 7 days =>
    7 (duration of treatment)* 1.5 (DDD)/ 0.5 (dose of medicine per unit in grams) = 21 tablets
    Amoxicillin 500mgcourse is 21 tablets.

Access group antibiotics

Code Article DDD U AWaRe Age unit_per_course
DINJAMPI1V- AMPICILLIN, 1g, powder, vial 6.00 g Access 5 years or more 6
DINJAMPI5V- AMPICILLIN, 500mg, powder, vial 2.00 g Access Under 5 years 6
DINJCEFA1V- CEFAZOLIN, 1g, (IV), powder, vial 3.00 g Access 5 years or more 6
DINJCLOX5VV CLOXACILLIN sodium, eq. 500mg base, powder, vial IV 2.00 g Access 5 years or more 6
DINJGENT8A- GENTAMICIN sulfate, eq. 40mg/ml base, 2ml, amp. 0.24 g Access 5 years or more 6
DINJMETN5BF METRONIDAZOLE, 5mg/ml, 100ml, bag/bottle PVC free 1.50 g Access 5 years or more 5
DINJPENB2VS BENZATHINE BENZYLPENICILLIN, 2.4 MIU, powder, vial + solvent 3.60 g Access 5 years or more 4
DORAAMOC22TD AMOXICILLIN 200mg/ CLAVULANIC acid, 28.5mg, disp. tab. 1.50 g Access Under 5 years 14
DORAAMOC4S5 AMOXICILLIN 400mg / CLAV.ac. 57mg/5ml, powd.oral susp. 70ml 1.50 g Access Under 5 years 1
DORAAMOC56T AMOXICILLIN 500mg / CLAVULANIC acid, 62.5 mg, tab. 1.50 g Access 5 years or more 18
DORAAMOC81T AMOXICILLIN 875mg / CLAVULANIC acid 125mg, tab. 1.50 g Access 5 years or more 14
DORAAMOX1S1 AMOXICILLIN, 125mg/5ml, powder oral susp., 100ml, bot. 1.50 g Access Under 5 years 1
DORAAMOX2TDB AMOXICILLIN, 250mg, dispersible and breakable tab. 1.50 g Access Under 5 years 21
DORAAMOX5T- AMOXICILLIN, 500mg, tab. 1.50 g Access 5 years or more 21
DORACEFX2C- CEFALEXIN, 250mg, caps. 2.00 g Access 5 years or more 56
DORACLOX2C- CLOXACILLIN sodium, eq. 250mg base, caps. 2.00 g Access 5 years or more 56
DORADOXY1T- DOXYCYCLINE salt, eq. 100mg base, tab. 0.10 g Access 5 years or more 10
DORAMETN2S- METRONIDAZOLE benzoate,eq.200mg/5ml base,oral susp,100-120ml 2.00 g Access Under 5 years 1
DORAMETN2T- METRONIDAZOLE, 250mg, tab. 2.00 g Access 5 years or more 20
DORAMETN5T- METRONIDAZOLE, 500mg, tab. 2.00 g Access 5 years or more 20
DORANITR1T- NITROFURANTOIN, 100mg, tab. 0.20 g Access 5 years or more 14
DORATINI5T- TINIDAZOLE, 500mg, tab. 2.00 g Access 5 years or more 4

Watch group antibiotics

Code Article DDD U AWaRe Age unit_per_course
DINJCEFO5V- CEFOTAXIME sodium, eq. 500mg base, vial 2.0 g Watch Under 5 years 6
DINJCEFT1V- CEFTRIAXONE sodium, eq. 1g base, powder, vial 2.0 g Watch 5 years or more 6
DINJCEFT2V- CEFTRIAXONE sodium, eq. 250mg base, powder, vial 2.0 g Watch Under 5 years 3
DORAAZIT2T- AZITHROMYCIN, 250mg, tab. 0.3 g Watch 5 years or more 6
DORAAZIT3S- AZITHROMYCIN, 200mg/5ml, powder oral susp., 30ml, bot. 0.3 g Watch Under 5 years 1
DORAAZIT5T- AZITHROMYCIN, 500mg, tab 0.3 g Watch 5 years or more 3
DORACEFI2S- CEFIXIME, 100mg/5ml, powder for oral susp., 60 ml, bot. 0.4 g Watch Under 5 years 1
DORACEFI2T- CEFIXIME, 200 mg, tab. 0.4 g Watch 5 years or more 10
DORACIPR2T- CIPROFLOXACIN hydrochloride, eq. 250mg base, tab. 1.0 g Watch 5 years or more 20
DORACIPR5T- CIPROFLOXACIN hydrochloride, eq. 500mg base, tab. 1.0 g Watch 5 years or more 14
DORAERYT5T- ERYTHROMYCIN stearate, eq. 500mg base, tab. 1.0 g Watch 5 years or more 18
DORAFOSF3S- FOSFOMYCIN trometamol, eq. 3g base, sachet 3.0 g Watch 5 years or more 1

Access vs Watch AB

BEmONCs and CEmONCs included

Mission’s ratio of Access to Watch - 5 years or more

Mission’s ratio of Access to Watch - Under 5 years

good ratio (within target)

good ratio

tendency to prescribe more Watch (second lines)

higher tendency to preiscribe Watch

Percentage of AB prescription to consultation

PHCs and MCs only

Mission’s Percentage of Antibiotics & Antipyrretics to consultations - 5 years or more

Mission’s Percentage of Antibiotics & Antipyrretics to consultations - Under 5 years

good ratio

good ratio

abnormal ratio - needs investigation

Abnoraml ratio - needs invistigations

Observation & Recommendations

Observations:

  1. In general, there is a high rate of antibiotics consumption, this is even higher in mobile activities and pediatric consultations.
  2. In some facilities, the number of Abx courses delivered is higher than the number of consultations. This needs investigation, beginning from assumptions about consultation registration in HMIS to Abx prescription habits.
  3. Overall, there is a high tendency to prescribe the Watch antibiotics group for pediatrics in all HFs.

Observations:

  1. The ratio of antipyretic/analgesics to antibiotics is unexpected, this is especially true for Under 5 Years patients.

Recommendations:

  1. Investigate the practices for the HFs with higher ratio AB courses/consultations: reporting/inventory related issues could impact the analysis, and treatment duration.

  2. Emphasize on the importance of respecting protocols and guidelines (fight against AB resistance…).

  3. double check the registration and data entry, there is errors caused by data registry errors

Syria Mission’s PHC and MC Antibiotics analysis